Month: March 2017

“Although numerous propositions have been put forward in the literature about how we might usefully subclassify low back pain (LBP), we must first consider the potential utility and futility of such aspirations and ask, “Will it change the outcomes of patients?”

This first statement in the paper is great. All therapist classify patients using either a sophisticated method (which will be spoken of in this paper) or a method that lacks sophistication (a patient’s education level, income level, etc). The big question that we have to ask is “does any of it really matter”.

“Within this arena, there are two schools of though-nominalist and essentialist. Nominalists define a disease by its symptom profile (CLBP = back pain of duration > 3 months). Essentialists state that each specific disease has an underlying pathophysiology, implying treatment of the disease requires treatment of the pathology”

This is fun for me to read. I never though of it this way, but I guess that I would be a nominalist in most cases. Rarely do I believe that the underlying pathophysiology must be treated in order to resolve symptoms. Let me give you an example. For patients that have degenerative disc disease (this is a very common diagnosis in the clinic and most will have this over the course of the lifetime) there is nothing that I will do to regenerate the disc, but I may be able to teach the patient how to either shut off the pain or manage the pain. This would be the nominalist in me. The essentialist in me has another example, which is also a real example in the clinic. There was a patient coming to therapy for treatment of his shoulder. In the process of treating the shoulder he developed back pain (not while in the clinic with me). Anyway, he neglected to tell me about the back pain, but later in the course of care (all within a couple of weeks) went to an urologist for urinary issues. He never told his urologist about the back pain and was advised to use a catheter to urinate! Anyway, he told me about his catheter issues and I was curious. I asked if he was experiencing any back pain or leg pain and sure enough he was. I called a surgeon that I trust and the patient was in surgery within a day. He had an issue that required surgical correction of a pathological issue. In this case, I am an essentialist. Now that I think about it, I am not sure if one can root for only one team.

“These classifications can broadly be divided into three groups: (1) those that consider clinical descriptors, (2) those that describe prognosis, and (3) those that consider response to treatment.”

I am credentialed in Mechanical Diagnosis and Therapy, formerly known as the McKenzie Method. In this respect I am a little biased and it is important that you guys know that I am biased towards one method before reading the rest of the article. MDT would be a patient response approach.

Other systems, such as the Treatment Based Classification System (TBCS), which wasn’t even considered in this article it looks like, is a system that is based on clinical prediction rules. This means that if you come in and say some key words and test positive on some key tests that it would dictate a specific category of treatment, which is completely different from a patient that speaks of different key words and test negative on key tests.

“We identified 28 classification systems of CLBP (chronic low back pain)…systems that described subclasses based on pathoanatomy, pahtophysiology, or clinical signs and symptoms without attempting to predict outcome or direct treatment were labeled as ‘diagnostic’…systems attempting to predict outcome irrespective of treatment were termed ‘prognostic’…systems that suggested treatments for different subclasses were termed ‘treatment based’…16 diagnostic, seven prognostic, and five treatment-based classification systems for CLBP.”

Typically, when I am writing a blog post I go to the back of my library (actually a trunk in the crawlspace) and grab an article that I read years ago. (I know…I am a nerd because I keep research articles that I read years ago). Anyway, re-reading the highlights of this article is like reading the article for the first time. I forgot that there were this many classification systems out there. Typically only a few are spoken of in the clinic and these are: the movement impairment system, Quebec Task Force, Mechanical Diagnosis and Therapy, Treatment Based Classification System and the Canadian Back Institute Classification System.

I will have to read the highlights of the article again in order to figure out which system fits into which category.

“The first description of a treatment based system was by McKenzie, who classified patients into three main syndromes based on physical signs, symptom behavior, and their relations to end-range lumbar test movements”

Is it wrong that I was pounding my chest when I was typing the above sentence? This reminds me that I will have to write a blog on the history of MDT. One can see the history of MDT in the book Against the Tide.

“Riddle and Rothstein assessed 49 physical therapists with varying clinical experience, in their ability to classify 363 patients according to the McKenzie system. Their ability to agree at the subsyndrome level was poor…Agreement among examiners was only marginally improved for classification into the three main syndromes…Agreement among examiners was better in three studies that assessed physical therapists who completed a certification in the McKenzie method with percent agreement ranging from 74% to 91% for subsyndromes and 93% to 100% for main syndromes.”

This tells us a few things. First is that those certified in using a method are actually good at using the method and those that aren’t certified aren’t as good at using a method. I think that this thought process would hold true for many aspects of different professions. I actually had a discussion on FB about this topic and I don’t think that it is the magic of the certification that increases agreement, but the hours upon hours of studying that went into preparation for the test that increases therapist’s competency of using a method. When a therapist is certified though, the agreement is close to perfect.

“Movement System Impairment classification…proposed by Van Dillen et al and includes five categories based on signs and symptoms elicited with direction-specific tests in the direction of lumbar flexion, extension, rotation, rotation with flexion, or rotation with extension…shown to be reliable in three different studies”

I’ll have to read more about this system because at a glance it sounds eerily similar to McKenzie’s method. Both appear to have a “directional preference” based treatment and avoidance (I’ll assume only temporarily) of the aggravating factors.

“Canadian Back Institute Classification system…recognition of syndromes or patterns of pain with no direct reference to pathoanatomy…the classification was based on the location of dominant pain, whether the pain was constant or intermittent, and which movements or postures exacerbated or alleviated the symptoms…shown to be reliable in one study.”

Again…these systems are starting to sound familiar and similar to each other. Figure out the symptom location, what makes them worse, what makes them better, is it mechanical or chemical and then name it for what it is. This appears to be the same in the three classification systems.

“Movement and Motor Control Impairment (MCI) classification system by O’Sullivan proposed treatment based on subgroups of patients with CLBP categorized by five distinct patterns based on a specific direction of MCI…flive categories included flexion pattern (loss of motor control into trunk flexion resulting in excessive abnormal flexion strain), flexion/lateral shifting pattern (MCI around the lumbar spine with a tendency to flex and laterally shift at the symptomatic segment), active extension pattern (MCI around the lumbar spine with a tendency to hold the lumbar spine actively into extension), passive extension pattern (loss of lumbar motor control around the lumbar spine with a tendency to passively overextend at the symptomatic segment), and multidirectional pattern (MCI around the lumbar spine in multiple directions)…The percent agreement was 70%.”

It seems like this system is all about a loss of control at the lumbar spine. The agreement of classification isn’t bad at 70%. I struggle with this system because it does not appear to be a patient response based system. I’ll have to read more into this system. The first thing that I think of is “how do we know if we are doing the right thing and how long do we have to wait in order to determine if we are moving in the right category.

“An RCT assessed the classification system by McKenzie by randomizing 260 patients into two groups: Group A was treated with the McKenzie method, and group B was treated with intensive dynamic strengthening training…tendency toward a difference in reduction of disability using the Low Back Pain Rating Scale in favor of the McKenzie group at the 2-month follow-up assessment, but no differences at the end of treatment (4 months) and at the 8-month follow-up evaluation.”

Some would look at this and say that MDT was no better than strengthening at 4 and 8 months. Others would look at it and say that MDT was better than strengthening at 2 months. If you were a patient, which would you rather have? Would you rather be better at 4 months or two months…knowing that you would be at the same place in 8-months? This study doesn’t seem too realistic in that once a patient is improved with MDT, then the treatment would transition towards a functional strengthening phase.

“…overall strength of evidence …is High for the McKenzie and Movement Impairment Classification systems, especially when examiners have been extensively trained; Insufficient for the Canadian Back Institute Classification; and Moderate for the MCI Classification”

This sentence sums it up. MDT has moderate evidence to support that it is highly reliable. The Canadian Back Institute Classification system has low evidence to show that it is insufficiently reliable.

If I were a therapist going to learn a new method, I would have to start with MDT based on the volume of studies demonstrating reliability.

“Once it is established that patients can be classified reliably, it then must be demonstrated that by directing a specific treatment at the subgroup, one can expect an improvement in treatment outcomes.”

This means that once we know what we are seeing…can we fix what we see? What is the purpose of classifying a patient into a group if the treatment for that group is ineffective?

“This suggests that the ideal classification system should minimize the number of subgroups to ensure that the user can become confident (and competent) it its use with little training.”

Holy smoly do I disagree. We just said that the subgroups must lead to a specific treatment that performs better than other forms of treatment. If we minimize the number of subgroups, then we are minimizing the impact of subgrouping. For instance, if we state that there is only one subgroup, then what is the likelihood of the treatment for that one subgroup helping all of the patients? We already know that it’s pretty low…this is how we got into this mess to begin with. In the past, all low back pain was treated very similarly, with horrible effects. Now, if there is only one subgroup, we can be assured that most people would fit into this subgroup. Therefore, the therapists would be highly reliable in choosing the group in which to place the patient. THIS DOESN’T MEAN THAT IT WILL ACTUALLY BE EFFECTIVE TREATMENT!

Back pain is very costly in the US. We need to do a better job of minimizing the disability from LBP and educating the patients regarding back pain natural course and how to live and manage this ailment. There have been other systems created since this article was published in 2011 and we will see how these systems fair over time.

I’ve been writing blogs now for about a year. Soon will be the 100th blog post. I don’t make anything for this. I don’t get any recognition for this. Big picture, there is no incentive for me to do this blog. So why do it?

I owe it to the profession that has given me the capabilities to treat patients, make a living, and pay my bills. My job is not that hard. I don’t have to dig ditches (what my dad did for a living working in water and sewer), I don’t have to drive a forklift (which is what I did prior to going into PT school), I don’t have to teach kids in high school (which is what I initially intended to do). This job of a Doctor of PT is not that bad.

Looking at it realistically, writing this blog actually makes me a worse clinician. I spend a lot of time reading. Instead of spending 30-40 minutes typing a blog weekly, I could be reading to enhance my own knowledge of the profession. I could be reading to improve my skills. I could be spending extra time with my family. There are a lot of things that I could be doing instead of writing the blog. This isn’t a rant, but why do I do it?

I have students that come through me as a clinical instructor. It is my responsibility to pass off the knowledge that I obtained over my years in the profession. It is my responsibility to coach up others around me and those in the profession that may not have the want to actually do the research themselves. There is a saying on a t-shirt that I read in a Crossfit arena that says something to the effect: the only knowledge wasted is the knowledge not shared. This really hit home for me. I spent a lot of time acquiring knowledge through reading books, research articles, spending time in the gym, watching youtube videos and so on and so forth. I have a lot of hours put into increasing my knowledge and now that I think of it…it would all be for a waste if I don’t attempt to share it.

I owe a big thank you to Dr. Ben Fung for inspiring this blog. I owe a thank you toDr. Mickey Shah for his years of mentorship through my growing process.

If any of you have a topic that you would like to see covered on this blog in the future, please send me the topic and I will do the work of reading and writing about the research.

Lumbar spinal stenois (LSS)…defined by any narrowing of the spinal canal and/or nerve root canals…In patients with severe LSS, a space reduction of 67% has been found in the spinal canal.”

Spinal stenosis is the narrowing of the holes of the spine. The spine has 3 holes in it in the lumbar region. Each hole carries a nerve. It could either be the nerve of the spinal cord down the middle, and larger, hole. It could be the nerve roots out of the holes on the side of the spine. Each hole needs to be big enough so that it doesn’t irritate the nerve that it allows to pass through the hole. Picture a water pipe. If you put too much stuff in the pipe it will clog up. Sometimes there are tissues that can make their way into the holes of the spine to clog the holes. When the hole is clogged, the nerves don’t have as much room to do their job (transmitting signals to and from the brain). Now take that same pipe and come back and look at it over decades. There will be sludge and stuff built up around the pipe. This is essentially creating a smaller diameter on the inside of the pipe. This smaller diameter due to sludge is also creating a smaller hole. This could happen in the spine with severe arthritis or degenerative disc issues in which the hole gets smaller. A visual is much better so maybe this will help. image for spinal stenosis

“…estimated the incidence of LSS in Denmark to 272 per one million inhabitants per year”

In other words, it is not very common in Denmark.

“…it is important to discriminate between LSS and disc generated pain since these conditions have different prognoses and the range of evidence based treatments are different, as well.”

The treatment between the two issues, discogenic back pain and stenotic back pain, is very different. A thorough evaluation can start to correlate symptoms with either discogenic pain or non-discogenic pain. Many patients believe that an MRI will be the answer to why they have pain, but unfortunately this isn’t so.

“a valid and reliable clinical assessment protocol for identifying LSS would be valuable in terms of choosing relevant treatment and informing the patient about the prognosis as early as possible.”

This article was written in 2009. The medical profession has existed for eons. There is still not a valid way to assess a patient in order to determine spinal stenosis. There are biologically plausible ways, meaning that when I assess you, I can make an educated guess from some of the findings in the history and physical, but it is not a valid (proven) way of coming to a conclusion.

“The high sensitivity and specificity of MRI suggests this is a good test for ruling in and out the disease.”

The MRI does a great job of telling us what is abnormal, but it doesn’t do a great job of telling us if the abnormal finding is causing symptoms. As seen in the link above, there are abnormal findings in a population without symptoms. We have to take the imaging findings and see if they make sense after performing a physical exam.

“…history will provide strong clues to the presence of spinal stenosis…more than 65 years of age…prolonged history of low back pain and intermittent radiating symptoms having developed gradually…limited walking capacity…Movements or positions involving flexion e.g. sitting or stooping, will often abolish symptoms…total loss of lumbar extension range is usually found, while flexion most often is well preserved.”

The typical patient with lumbar spinal stenosis will notice that the ability to walk has gradually reduced over time and there is a need to sit due to back or leg pain. Sitting will typically turn down or off the symptoms rapidly. This patient will have limited motion into extension (think of looking over your head to see the stars or bending backwards while standing).

“…stenosis from zygapophyseal joint hypertrophy, ligament thickening or other degenerative changes, it cannot be expected that physical exercise or manual treatment will create a lasting change in the degree of space reduction in the spinal canal or intervertebral foramina”

In the presence of physical changes to the bones, ligaments or loss of disc height, there is nothing that a PT can do to change these back to the way that they were previously. These have been described as wrinkles on the inside. If we look at your face we can start to see how much age you have based on the wrinkles in the face. This is also done on the inside in that some “degenerative” changes are normal. Wrinkles are normal; they are not symptoms of anything sinister. The same can be said for physical changes on the inside. They don’t have to be pain generators. It takes a physical exam to determine how your symptoms respond and whether or not this matches the images on an MRI or X-ray. Even then, we can’t say that movement won’t help, only that we won’t change the physical “inside wrinkles”.

“The main purpose of this pilot study is to evaluate the validity and intertester reliability of an algorithm of physical examination tests, in relation to identifying symptomatic lumbar spinal stenosis.”

This is good. A pilot study is like a pilot for a t.v. show. This is done to see if additional episodes should be done. This study will conclude if additional studies on this topic should be done. What it hopes to find is a reliable (consistent) way of determining validity (actually seeing what the test hopes to see) in testing for lumbar spinal stenosis. A test that is both reliable and valid should be able to test for spinal stenosis regardless of who is performing the test and who is measuring the test.

“Two patients were classified as “LSS” and five patients “Not LSS”, meaning a 29% prevalence of “LSS” Intertester agreement for overall diagnostic conclusion was 100%”

There are so few patients that this study will likely not yield any results that are actionable. The interesting thing is that the examiners agreed 100% of the time. This is not common in the medical field to have 100% agreement on near anything.

“…the algorithm in its present form can not be used as a screening test to rule out LSS, although it may be able to diagnose the condition.”

There were so few people in the study that it is hard for any clinician to put it to use in the clinic. It may be able to diagnose the condition in that it demonstrated a specificity of 1.0, which is really good.

“ Low back pain (LBP) is though to occur in almost 80% of adults at some point in their lives”

This is an article from the 1980’s. It’s been over 20 years since this article was written and these statistics still hold true over time. As much as we have advanced technologically, it doesn’t really seem to be helping the prevalence of back pain. I’ve seen in places where this is called the common cold of musculoskeletal issues because it will affect so many people over the course of a lifetime.

“…back problems are the most frequent cause of limitation of activity (work, housekeeping, or school) in persons younger than 45 years.”

This is a problem. If I have to take time off of work because of back pain, then there is less food on my table. I’m sure that this holds true for many of those reading this blog. We have to do better. Back pain doesn’t have to disable a person. We need to do a better job of educating the public regarding back pain. There was a recent article that notes that people should try drug-free options first for low back pain. PT is one of those “drug-free” options.

Every day about 1,000 people are treated in the emergency department for misuse of opioids. About 40 people per day die of opioid overdose. These numbers are staggering! It doesn’t have to be so.

This may have changed in the past 20 years. I read recently that back pain accounts for more visits than all other issues except for respiratory tract symptoms (i.e. the common cold). This is a lot of people with back problems. Not many patients are referred to PT. There is an article that reports about 7% of patients seek out PT. When they do get referred, not all PT’s practice with the same treatment parameters. Do your research as to what clinic you are attending, because they are not all the same in regards to cost and effectiveness.

“A variety of exercise regimens for LBP has been advocated. The three most commonly recommended regimens are (1_ hyperextension exercises to strength paravertebral muscles; (2) general “mobilizing exercises” to improve overall spinal range of motion; and (3) isometric flexion exercises designed to strengthen both abdominal and lumbar muscles, creating a “corset of muscles.”

Lots has changed in the research, but unfortunately not a lot has changed in practice from my point of view. I still see the same “core stability” training done on many patients even though the research doesn’t support one type of “core training” over another. There have been more interventions added to the research and application, such as thrust manipulations, directional preference based exercises, cognitive behavioral therapy and others just to name a few.

“Several trials shoed no advantage of traction over alternative treatments, but statistical power was not reported.”

This article is over 20 years old! The advice at that time is similar to the current stance based on the research. The problem with this is that there are still many therapists using traction. Saying this differently, there are still some therapists that frequently use traction. This could only be for one of two reasons:

Ignorance. As much as I would love to say that all therapists are reading journal articles at home, we know that this is not the case. Based on some research, there are therapists that don’t even know how to find the research and if they can find it, they won’t take the time out of their day to read it. This is a problem because it is our profession. I never stop wearing the hat of physical therapist, in the same light as I never stop wearing the hat of husband and father.

Greed. A therapist doesn’t need to spend much time with the patient while they are on traction. Traction is paid whether the therapist is by your side or not. In this fashion, the therapist can spend time with another patient and charge that other patient for his/her time while the therapist is charging you for traction.

Don’t get me wrong; there are cases in which to use traction. When it is the last viable option to try to get a patient better or to keep the patient from an unwanted surgery. In other words, it is used as a last case scenario. You can see a previous post on traction if you are interested.

“For these reasons, its (bed rest) value for patients with typical findings of a herniated disk is not disputed…Thus, there is suggestive evidence for the efficacy of strict bed rest for some patients without sciatica…”

Wholly Moley! This has changed dramatically. Bed rest is rarely recommended for anything. The repercussions of spending hours to days in bed far outweigh standing with benign low back pain. This article summarizes the negative effects.

“Spinal manipulation remains highly controversial, partly because in the United States it is often equated with the practice of chiropractic.”

Physical Therapists are able to manipulate the spine and other areas of the body. No one profession owns this treatment. Chiropractors have done a much better job of educating the public about the treatments that they perform. Don’t be surprised if your therapist wants to perform a manipulation. Lot’s has changed in 20 years.

“This study did serve to demonstrate that placebo effects with a nonfunctioning stimulator are common”

This is interesting that the thought of TENS (a form of treatment in which pads are placed on a specific body part and an electrical current is introduced throughout the pads in order to reduce pain) 20 years ago was that it could also be the placebo effect that is creating the change. Patients seem to like it in the short-term, but there is major controversy over this intervention. So much so that medicare questions its effectiveness for back pain.

“The use of corsets, TNS (TENS), and conventional traction are not yet supported by any rigorous trials.”

This was stated 20 years ago! I believe that if you walked into any physical therapy clinic that you would still see these interventions applied to the patient…because insurance companies continue to pay for them. Although there is much research to indicate that these interventions have little to no place in therapy, many times their use is due to the two reasons given above. If you are in a place in which these are the treatments that take up a majority of your sessions, question your therapists. This is the advice given by the professional organization of physical therapists, the APTA.